Crystal Ridge Care Center
396 Dorsey Drive, Grass Valley, CA 95945
Citation Number: 230008564
Citation Date: 09/21/2011
Violation Date: 2/8/2011
Class: AA
Penalty: $ 75,000

CITATION NUMBER: 23-2519-0008564-F

CLASS AA CITATION -- PATIENT CARE

F 323 483.25(h) FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES
The facility must ensure that the resident environment remains as free of accident
hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents.

Unannounced visits were made to the facility on 2/15/11, 2/16/11, 2/22/11 and 5/10/11 to investigate entity reported incident 258504 regarding Resident 1's death after sustaining a fall. This citation was written as a result of observations, staff written statements, and interviews and clinical record review.

The Department determined that the facility failed to:

Ensure that Resident 1 remained free of injury while being transferred out of a bathtub via a mechanical lift chair, when on 2/8/11 at 9:45 am, certified nursing assistant (CNA 1) transferred Resident 1 out of a bathtub via a mechanical lift chair by herself. Based on the facility's Mechanical Lift policy, CNA 1 was required to have two persons to transfer Resident 1 when using a mechanical lift chair. This failure resulted in Resident 1 falling out of the mechanical lift chair into the bottom of the empty bathtub, where he sustained a large gash on his head and three broken bones in his neck. Resident 1 died four days later on 2/12/11.

On 2/14/11, the facility notified the Department that Resident 1 had died on 2/12/11 after sustaining a fall at the facility on 2/8/11.

Resident 1's skilled nursing facility (SNF) clinical record was reviewed on 2/15/11, 2/16/11 and-2/22/11. Resident 1 had been readmitted to the facility on 1/15/11 with diagnoses that included heart disease, high blood pressure, weakness, and kyphosis (severe curvature of the spine: sometimes referred to as humpback). Resident 1's care plan, dated 1/15/11, indicated that he was at risk for falls related to his poor body posture, weakness, inability to reposition self, and need for assist with transfer. The initial Physical Restraint Assessment form, dated 2/1/11, contained documentation that the facility was using a self release seat belt for safety due to Resident 1 's inability to consider his own lack of independence and that he falls/slides out of chairs. The Minimum Data Set (an assessment tool), dated 1/25/11, noted that Resident 1 was alert and able to make his needs known. He required extensive assistance (meaning that Resident 1 was involved in the activity but required staff to provide weight-bearing support) for transfers.

On 2/6/11, Resident 1 had been placed on hospice care due to his declining condition, which included progressive muscle weakness that resulted in his inability to sit upright without support. CNA 1 was a hospice CNA who had been caring for Resident 1 on 2/8/11 through a facility contract with the hospice agency.

The facility's Mechanical Lift policy, undated, provided by the facility's Director of Staff Development indicated that, " ... Assistance of two personnel will be used with Mechanical Lift ... "

On 2/8/11 at 9:45 am, CNA 1 transferred Resident 1 out of a bathtub via a mechanical lift chair by herself. CNA 1 turned away from Resident 1 to get a towel and he fell forward from the lift chair into the bottom of the empty bathtub. He sustained a nine and a half inch gash on the top of his head, was covered with blood, and was complaining of neck pain.

In an interview with CNA 1 on 2/16/11 at 4:30 pm, she stated that 2/8/11 was the first time she had provided care for Resident 1 and she was not familiar with his care needs. She also stated that the last time she had given a resident a tub bath using a mechanical lift was a, "few months prior." CNA 1 also stated that she was aware that the use of a mechanical lift chair for transfers required two persons. She stated that on the morning of 2/8/11, she and a second CNA (CNA 5), transferred Resident 1 from his bed to the portable portion of the chair lift, wheeled him into the shower room, and together transferred him into the bathtub. She declined further assistance from CNA 5 who then left the room. In the written statement by CNA 1, dated 2/9/11, she indicated that when she was asked by CNA 5 if she had ever used the bathtub before when they were assisting Resident 1 into the bathtub, she documented, "yes, but it was a long time ago."

CNA 1 stated that, at approximately 9:45 am, while bathing Resident 1, he began leaning forward into the water. CNA 1 began draining the bathtub of water as she assisted Resident 1 back to an upright position, but he fell forward again. CNA 1 stated she requested assistance from other CNAs in the shower room, pulled the emergency cord and heard the alarms. At this point, she opted to transfer Resident 1 from the bathtub by herself. She had raised Resident 1 out of the bathtub via the mechanical lift chair and turned to grab a towel. CNA 1 stated she heard a sound and turned to see Resident 1 lying into the bottom of the empty bathtub. He was covered in blood and complaining of pain in his neck.

Review of investigative statements made by CNAs 2, 3, 4, and 5 document that CNA 4 was in the shower room when CNAs 1 and 5 brought Resident 1 into the room and transferred him into the bathtub. CNA 4 wrote that she heard CNA 1 say to Resident 1, "If you cannot keep your head above the water, then we will have to get out" CNA 4 asked CNA 1 if she needed help transferring Resident 1 out of the bathtub. CNA 1 responded that she, "Was okay, but in hindsight, she would not have given him a tub bath if she realized how contracted he was, he kept leaning very forward." CNAs 2 and 3 were in the shower room with another resident when they heard a noise and CNA 1 calling, "I need help". CNA 3 responded and saw CNA 1 trying to get Resident 1 out of the bathtub but it was too deep. CNAs 2 and 3 pulled the emergency light and CNA 2 went for help. CNA 4 had left the shower room, saw the red light on, and responded with several other CNAs.

Resident 1 was removed from the bathtub by paramedics and transferred by ambulance to an emergency room on 2/8/11 at 10 am. The Emergency Room record, dated 2/8/11, noted that Resident 1's head wound was stitched closed. X-rays of his neck revealed, "1. Acute mildly displaced obliquely oriented (diagonally or slanted) fracture through the odontoid process (a tooth like projection from the upper surface of the body of the second cervical (neck) vertebra (one of 7 bony segments of the spinal column in the neck); 2. Acute mildly displaced fracture of the anterior arch (front bowlike structure) of C1 (first neck vertebra); 3. There is antero-infero-lateral (a frontward, downward, to the side) subluxation (partial or incomplete dislocation) of the right lateral mass (right side of second neck vertebra) and there is a small associated impaction (ends of bones wedged together) fracture of the pedicle (the bony process which projects backward from the body of the vertebra) of C2 (second neck vertebra). Resident 1 had two broken vertebrae in the neck. One of those two vertebrae (C2) had two separate breaks. He was returned to the facility on 2/8/11 at 4:05 pm.

Physician (MD) A's progress notes, dated 2/10/11 at 6 am, read that Resident 1, " ... had a very traumatic fall 2 days ago with UNSTABLE C1-C2 (cervical neck) fracture (broken bones in neck) and closed head injury ... was not a surgical candidate and was unable to be fitted with a traditional C-spine collar (neck support) due to severe kyphosis ... Spoke with wife ... bluntly told her that with patient's ... non immobilization that he would probably die from aspiration pneumonia or P.E. (pulmonary embolism - a clot in the lungs) ... goal with patient will be comfort care and ultimately a peaceful death."

During an interview with MD A on 7/12/11 at 4:50 pm he stated that C1-C2 fracture injuries (broken neck bones) often caused interference with the functioning of a major nerve from the neck region of the spine that carried impulses to the diaphragm (breathing muscle). This interference had the potential to cause paralysis of the diaphragm and lead to respiratory (breathing) failure and death.

A certified copy of the Death Certificate, dated 2/15/11, listed the cause of death on 2/12/11 as, "(A) Respiratory Failure; (B) C1-C2 Fracture - Unstable; (C) Head Trauma; (D) Mechanical Fall"

In an interview with Director of Staff Development (DSD 6) on 2/15/11 at 10:50 am, she stated she had not performed any training to CNAs, including hospice CNAs for the use of the mechanical lift chair for the bathtub. She stated that she took the hospice CNAs "word" that they were competent to use the mechanical lifts.

In an interview with the Administrator on 2/22/11 at 2:45 pm, he stated that the facility did not use a checklist to verify competencies of hospice CNAs. The Orientation Checklist provided by the Hospice facility for CNA 1 did not contain any documentation that she had been trained on the use of a mechanical lift. The document titled, "Evaluation of Hospice Aide Competency" dated 7/22/10 for CNA 1, had a blank area for evaluating her competency to perform a, "tub bath."

In an interview with CNA 1 on 5/10/11 at 3:30 pm, she stated she had been trained on the use of a chair lift in 1998 but did not remember being checked that she was competent to use the lift.

Therefore, the facility failed to ensure that Resident 1 remained free of injury while being transferred out of a bathtub via a mechanical lift chair. On 2/8/11 at 9:45 am, CNA 1 transferred Resident 1 out of a bathtub via a mechanical lift chair by herself. She was required to have two persons to transfer him when using a mechanical lift chair. This resulted in Resident 1 falling out of the mechanical lift chair into the bottom of the bathtub, where he sustained a large gash on his head and three broken bones in his neck. Resident 1 died four days later on 2/12/11.

This violation presented, either an imminent danger that death or serious harm would result or, substantial probability that death or serious physical harm would result and was the direct proximate cause of the death of Resident 1.